Welcome to the 2013 Iowa Adverse Childhood Experiences Summit. Data into Action: Crafting a Response to Iowa s ACE Score

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1 Welcome to the 2013 Iowa Adverse Childhood Experiences Summit Data into Action: Crafting a Response to Iowa s ACE Score

2 Dr. Nadine Burke Harris Founder and Chief Executive Officer, Center for Youth Wellness

3 IOWA, LET S KICK SOME ACES! Nadine Burke Harris, MD, MPH CEO, Center for Youth Wellness October 14, 2013

4 CPMC Bayview Child Health Center

5 The ACEs Study Vincent J. Felitti, MD and Robert J. Anda, MD, MS Asked 26,000 adults at Kaiser, San Diego s Dept of Preventive Medicine. 17,421 participated in the study. Participants completed a questionnaire.

6 ACEs Criteria 1. Recurrent physical abuse 2. Recurrent emotional abuse 3. Contact sexual abuse 4. An alcohol or drug abuser in the household 5. An incarcerated household member 6. Someone who was chronically depressed, institutionalized, or suicidal 7. Mother treated violently 8. One or no parents, or parents divorced. 9. Emotional or physical neglect

7 Results 12.6% of population had ACE score 4 Dose-Response relationship between adverse childhood events and numerous organic diseases. Person with an ACEs score of 4 is 260% as likely to have COPD than a person with a score of 0.

8 Headaches Each of the ACEs was associated with an increased prevalence and risk of frequent headaches. As the ACE score increased the prevalence and risk of frequent headaches increased in a "dose-response" fashion. The risk of frequent headaches increased more than 2-fold (odds ratio 2.1, 95% confidence interval ) in persons with an ACE score 5, compared to persons with and ACE score of 0. The dose-response relationship of the ACE score to frequent headaches was seen for both men and women.

9 COPD Compared to people with an ACE Score of 0, those with an ACE Score of 4 had 2.6 times the risk of prevalent COPD, 2.0 times the risk of incident hospitalizations, and 1.6 times the rates of prescriptions (p<0.01 for all comparisons). These associations were only modestly reduced by adjustment for smoking. The mean age at hospitalization decreased as the ACE Score increased (p<0.01). Anda RF, Brown DW, Dube SR, Bremner JD, Felitti VJ, Giles WH. Adverse childhood experiences and chronic obstructive pulmonary disease in adults. Am J Prev Med 2008;34(5):

10 Lung Cancer Compared to persons without ACEs, the risk of lung cancer for those with 6 ACEs was increased approximately 3-fold. After a priori consideration of a causal pathway (i.e., ACEs --> smoking --> lung cancer), risk ratios were attenuated toward the null, although not completely. For lung cancer identified through hospital or mortality records, persons with 6 ACEs were roughly 13 years younger on average at presentation than those without ACEs. Brown DW, Anda RF, Felitti VJ, Edwards VJ, Malarcher AM, Croft JB, Giles WH. Adverse childhood experiences and the risk of lung cancer. BMC Public Health. 2010;10:20.

11 Liver Disease Each of 10 ACEs increased the risk of liver disease 1.2 to 1.6 times (P<.001). The number of ACEs (ACE score) had a graded relationship to liver disease (P<.001). Compared with persons with no ACEs, the adjusted odds ratio of ever having liver disease among persons with 6 or more ACEs was 2.6 (P<.001). The ACE score also had a strong graded relationship to risk behaviors for liver disease. The strength of the ACEs-liver disease association was reduced 38% to 50% by adjustment for these risk behaviors, suggesting they are mediators of this relationship. Dong M, Anda RF, Dube SR, Felitti VJ, Giles WH. Adverse Childhood Experiences and Self- reported Liver Disease: New Insights into a Causal Pathway. Archives of Internal Medicine 2003;163:

12 Ischemic Heart Disease Nine of 10 categories of ACEs significantly increased the risk of IHD by 1.3- to 1.7-fold versus persons with no ACEs. The adjusted odds ratios for IHD among persons with 7 ACEs was 3.6 (95% CI, 2.4 to 5.3). The ACE-IHD relation was mediated more strongly by individual psychological risk factors commonly associated with ACEs than by traditional IHD risk factors. Significant association was observed between increased likelihood of reported IHD (adjusted ORs) and depressed affect (2.1, 1.9 to 2.4) and anger (2.5, 2.1 to 3.0) as well as traditional risk factors (smoking, physical inactivity, obesity, diabetes and hypertension), with ORs ranging from 1.2 to 2.7 Dong M, Giles WH, Felitti VJ, Dube, SR, Williams JE, Chapman DP, Anda RF. Insights into causal pathways for ischemic heart disease: Adverse Childhood Experiences Study. Circulation 2004;110:

13 Autoimmune Disease First hospitalizations for any autoimmune disease increased with increasing number of ACEs (p <.05). Compared with persons with no ACEs, persons with 2 ACEs were at a 70% increased risk for hospitalizations with Th1, 80% increased risk for Th2, and 100% increased risk for rheumatic diseases (p <.05). Dube SR, Fairweather D, Pearson WS, Felitti VJ, Anda RF, Croft JB. Cumulative childhood stress and autoimmune disease. Psychom Med 2009;71,

14 Adverse Childhood Experiences vs. Smoking as an Adult % or more ACE Score p<.001

15 % Alcoholic Health Risks 18 Childhood Experiences vs. Adult Alcoholism ACE Score

16 % Have Injected Drugs ACE Score vs Intravenous Drug Use or more ACE Score p<0.001

17 % With a Lifetime History of Depression Chronic Depression >=4 ACE Score Women Men

18 % Have Injected Drugs Death Suicide Attempts or more 0 1 ACE Score

19 Prescription rate per 100 person-years) ACE Score and Rates of Antidepressant Prescriptions or more ACE Score

20 Percent With Health Problem (%) ACE Score and Teen Sexual Behaviors ACE Score or more 0 Intercourse by 15 Teen Pregnancy Teen Paternity

21 Relative Risk of disease for ACEs 4 (Iowa) Asthma 231% Diabetes 201% Heart Disease 285% Stroke 281% COPD 399%

22 Mechanism

23 Neurobiology

25 Stress Response Activation of the HPA Axis - release of adrenaline and cortisol Increase in sympathetic tone Activation of nor-adrenaline throughout the midbrain and forebrain including the cortex

27 Neuropathology Long term dysregulation of fight or flight response Loss of feedback inhibition leads to increased responses to subsequent stressors (hyper-arousal, irritability) Alterations mood and attachment (through changes is serotonin and GABA receptors) Difficulty with memory and learning (due to toxicity of the hippocampus) Increased high-risk and pleasure-seeking behavior (changes in the nucleus accumbens which is the reward center of the brain)

28 Multi-systemic Impacts Neurologic: HPA Axis Dysregulation VTA and reward center dysregulation Hippocampal neurotoxicity Neurotransmitter and receptor dysregulation Immunologic Increased inflammatory mediators and markers of inflammation such as interleukins, TNF alpha, IFN-γ

29 Effect of Child Maltreatment on Inflammatory Mediators

30 Multi-systemic Impacts Endocrine Adult ACTH and plasma cortisol levels directly correlate with adverse childhood events, neglect and depression measures. Maltreated children with PTSD were found to excrete greater than normal urinary cortisol and catecholamines years after disclosure of abuse. Long-term changes in cortisol, adrenaline and other hormones.

31 Multi-systemic Impacts Epigenetic Differential gene expression of pro-inflammatory transcription factors and neurotransmitter receptors Epigenetic modifications leading to the reduction of glucocorticoid receptors in the brain, resulting in a increased HPA activity under both basal and stressful conditions Changes in the way DNA is read and expressed leads to changes in the way the brain responds to stress.

32 National Scientific Council on the Developing Child Working Paper 10: Early Experiences Can Alter the Gene Expression and Affect Long-Term Development

33 Updated Mechanism

34 CPMC Bayview Child Health Center

35 CPMC Bayview Child Health Center ACEs % ACEs 4 12% ACEs 4 and BMI 85% OR: 2.0 p<.02 ACEs 4 and learning/beh probs OR: 32.6 p<.001 N.J. Burke et al/ Child Abuse and Neglect 35(2011)

36 Effect of ACEs on Educational Outcomes

Positive Stress Tolerable Stress Toxic Stress Normal and essential part of healthy development Brief increases in heart rate and blood pressure Mild elevations in hormonal levels Example: Tough test

37 Positive Stress Tolerable Stress Toxic Stress Normal and essential part of healthy development Brief increases in heart rate and blood pressure Mild elevations in hormonal levels Example: Tough test at school. Playoff game. Body s alert systems activated to a greater degree Activation is time-limited and buffered by caring adult relationships. Brain and organs recover Example: Death of a loved one, divorce, natural disaster Occurs with strong, frequent or prolonged adversity Disrupts brain architecture and other organ systems Increased risk of stressrelated disease and cognitive impairment Example: abuse, neglect, caregiver substance dependence or mental illness Intense, prolonged, repeated, unaddressed Social-Emotional buffering, Parental Resilience, Early Detection, Effective Intervention

38 Good news: Neuroplasticity! Brain architecture is experience dependent Social-emotional buffering makes a big difference Positive parenting Trusted mentor Healthy attachment Social-emotional skills

39 Neuroplasticity Cellular Plasticity Number of nerve connections Dramatically declines by age 5 Synaptic Plasticity Strength of individual connections Lifelong

40 Scope of the Challenge Impacts are pervasive and long-lasting Development Physical and Mental Health Social and Educational impacts Economic impacts Prevalence is high Strong evidence relating the risk Early intervention improves outcomes PUBLIC HEALTH APPROACH IS NECESSARY

41 How do we transform practice? Public Health Approach Public awareness campaign Public policy intervention Systems change Educational, financial, and logistical/administrative/systems support for: Basic science and translational research for the development of evidence-based practices, and Training for clinicians and researchers to develop and implement effective interventions.

42 Co-located Clinical Partnership 42 Bayview Child Health Center Center for Youth Wellness Universal ACEs Screening in Primary Care Home Bio-psycho-social assessment for Toxic Stress ACEs = 0 Yah! Nothing to do. Psycho-education (toxic stress, nutrition, self-regulation) ACEs = 1-3 w/o symptoms anticipatory guidance ACEs = 1-3 w/ symptoms Refer to CYW. ACEs 4 Refer to CYW. Home visits Psychotherapy Psychiatry Biofeedback Exercise Mindfulness and coping Tracking biological markers

43 Center for Youth Wellness PREVENT: Raise national awareness among those who have the power to make a difference. SCREEN: All children and youth at our center and train others how to screen. HEAL: Best practice mental health, holistic wellness, mindfulness, nutrition and movement integrated with primary care.

44 Thank You!

45 Resources Centers for Disease Control and Prevention UCSF Child Trauma Research Program Lucile Packard Early Life Stress Program National Child Traumatic Stress Network

46 References The Relationship of Adverse Childhood Experiences to Adult Health: Turning gold into lead Felitti, VJ Insights Into Causal Pathways for Ischemic Heart Disease: Adverse Childhood Experiences Study Dong et al, Circulation. 2004;110: Adverse Childhood Experiences and Chronic Obstructive Pulmonary Disease in Adults Anda et al, Am J Prev Med May; 34(5): Stress Predicts Brain Changes in Children: A Pilot Longitudinal Study on Youth Stress, Posttraumatic Stress Disorder, and the Hippocampus Carrion et al, Pediatrics 2007;119: Adrenocorticotropic Hormone and Cortisol Plasma Levels Directly Correlate with Childhood Neglect and Depression Measures in Addicted Patients Gerra et al, Addiction Biology, 13: Adrenergic Receptor Regulation in Posttraumatic Stress Disorder Perry et al, Advances is Psychiatry: Biological Assessment and Treatment of Post Traumatic Stress Disorder (EL Giller, Ed) American Psychiatric Press, Washington DC, , 1990

47 References Childhood maltreatment predicts adult inflammation in a life-course study Danese et al, PNAS, January 2007, Treatment o f Posttraumatic Stress Disorder in Postwar Kosovo High School Students Using Mind-Body Skills Groups: A Pilot Study Gordon et al, Journal of Traumatic Stress, 17(2): Mindfulness-Based Stress Reduction in Relation to Quality of Life, Mood, Symptoms of Stress, and Immune Parameters in Breast and Prostate Cancer Outpatients Carlson et al, Psychosom Med Jul-Aug; 65(4): Usefulness of the transcendental meditation program in the treatment of patients with coronary artery disease. Zamarra et al, Am J Card 1996 Apr 15;77(10): Alterations in Brain and Immune Function Produced by Mindfulness Meditation Davidson et al, Psychosomatic Medicine 65: (2003) Effect of buddhist meditation on serum cortisol and total protein levels, blood pressure, pulse rate, lung volume and reaction time. Sudsuang et al, Physiology & Behavior, Volume 50, Issue 3 September 1991, Pages

WHATEVER IT TAKES! UNDERSTANDING ADVERSE CHILD EXPERIENCES. Nadine Burke Harris, MD, MPH CEO, Center for Youth Wellness March 1, 2013

WHATEVER IT TAKES! UNDERSTANDING ADVERSE CHILD EXPERIENCES Nadine Burke Harris, MD, MPH CEO, Center for Youth Wellness March 1, 2013 Effect of ACEs on Health, Learning & Behavior Background Brief overview